Diabetes in Adolescents

Childhood obesity & diabetes have been linked by many studies; a paper published in Diabetes Care in 2011 by Ebe D’Adamo & Sonia Capro, titled Type 2 Diabetes in Youth: Epidemiology & Pathophysiology, is one of the more recent papers to have been written on the subject. The authors highlight the fact that the progression of obese children with insulin resistance to type 2 diabetes (T2DM) is faster than what’s seen in adults; this is made even more pertinent by the knowledge T2DM occurs more frequently in the second decade of life, coinciding with pubertal insulin resistance.

The knowledge of the occurrence of T2DM in adolescents has been quite recent; previously, the diagnoses of young people with diabetes were almost type 1 diabetes (insulin dependent diabetes). However, there has been a steady increase in the incidence of T2DM in children over the past few years, and this is mainly due to the concurrent rise in the incidence of childhood obesity seen in many urbanized countries.

South Asia, with its fast rate of development and urbanization, is now grappling with T2DM, similar to developed countries like the United States. The increase in childhood obesity in South Asia has been linked as a causal factor for this increased incidence of T2DM. A news article, published on 26th February 2012, in the Sunday Times (Sri Lanka) said that “one in four urban adolescents” had a high risk of developing diabetes. At that time, Dr. Mahen Wijesuriya, was carrying out a clinical trial, called DIABRISK-SL, to assess the efficacy of intensive lifestyle modification therapy in the young urban Sri Lankans. The patients for this study were screened on 4 risk factors: increased body mass index (BMI), increased waist circumference (WC), reduced physical activity and family history. The results were surprising: 24% of adolescents in the age group 10-14 had two or more risk factors for the development of T2DM. The study highlighted the lack of information with regards to diabetes, especially in the young population of Sri Lanka, seeing as 3 of the risk factors were modifiable risk factors, while the subject’s family history was not.

As per the recent Diabetes Atlas, available online from the International Diabetes Federation (http://www.idf.org/diabetesatlas), even though South East Asia has the lowest diabetes related expenditure in the world (mainly due to the public health sector), the region also has the highest mortality rate across the regions; Sri Lanka is the third highest country for number of people with diabetes.

With the World Diabetes Day coming up next week (November 14th) it is of great importance to realize that reducing childhood obesity can prevent the onset of diabetes in adolescents. This can be achieved with lifestyle modification, e.g. reduction in the intake of fast food and an increase in the amount of daily physical activity (to mention a few). This can only be achieved if more and more parents are educated and informed of the risk factors for adolescent T2DM and how to prevent them. It is also pertinent to educate parents about how to look for signs of diabetes and the importance of diagnosing diabetes early. However, a diagnosis of diabetes in your child does not mean that it is too late; control of the disease also involves eating well, regular exercise, taking medication regularly and routine care. With proper guidance & counseling, living with diabetes is made easy for the patient and immediate family members.

Intervention for pediatric diabetes is also gaining traction; there are many studies being carried out to assess new interventions with regards to controlling diabetes, aimed at increasing the efficacy of the intervention along with reducing unwanted side effects. RemediumOne is currently contracted with managing two pediatric (10-17 years) studies that assess the efficacy of a combination therapy compared to metformin monotherapy in the treatment of T2DM. These studies also have a lifestyle modification component for the patient, where they are advised by endocrinologists on how to change their diet & exercise regime to better cope with diabetes.

Sri Lanka Launches HeadPoST – The Largest Nursing Trial in the World

RemediumOne, in collaboration with The George Institute for Global Health, has successfully launched Head Position in Stroke Trial (HeadPoST). HeadPoST is the largest nursing care trial in the world with the aim of recruiting a sample size of over 19,000 patients.

Stroke is one of the most common causes for death around the world, claiming 6.2 million lives worldwide. This number of 6.2 million, is greater than the deaths due to AIDS, Malaria and tuberculosis put together. Every sixty seconds, even as you read this, 6 people are dying of a stroke. As you read this, every two seconds, somewhere, someone is having a stroke. In Sri Lanka, stroke is the 4th leading cause of hospital deaths.

Approximately 80% of strokes worldwide are ischemic in nature. They are caused by an artery clot, resulting in an immediate reduction in the blood flow to the brain parenchyma. This leads to a loss of oxygen supply to the brain and death of the brain tissue. Currently, limited therapies are available for the treatment of stroke. Following clinical diagnosis of an ischemic stroke, most patients are treated with a modern thrombolytic therapy and a recombinant tissue plasminogen activator, which act to dissolve the clot and restore the blocked vessel to re-perfuse the ischemic region of the brain. Several observational studies have suggested a simpler way of increasing blood flow to the brain, which is to tilt the head of ischemic patients into a “lying flat” (0?) head position. However, insufficient evidence is available to recommend a specific head position for ischemic patients.

HeadPoST is a multicentre, prospective, cluster randomized crossover, blinded trial conducted to compare the effects of “lying flat” (0?) head position with sitting up (30?) position applied within the first 24 hours of admission, for patients with an ischemic stroke, on the outcome of death and disability at 90 days. Data will be collected for 24 hours following admission to the hospital and at a 90-day blinded follow-up assessment.

Currently, RemediumOne is working with four of the best government stroke units of the country, namely Colombo North Teaching Hospital, Colombo South Teaching Hospital and Sri Jayawardenapura General Hospital. The study coordinated internationally, across 140 hospitals, by the George Institute for Global Health, which is one of the top ten research institutes in the world. The study is sponsored through a grant from the National Medical Research Council of Australia (NHMRC), a major government health research body, from 2014 to 2016. The trial is expected to run till the end of 2016, with recruitment to finish by mid-2016.

Parkinson’s – A disease burden for the elderly

Parkinson’s disease (PD) is the second most common progressive chronic neurodegenerative disease following Alzheimer’s disease (AD) (Gallegos et al., 2015). It affects approximated 2% of the world’s population over the age of 60 (Ouyang and Shen, 2006; Ikeda et al., 2008) and appears in two major forms, familial and sporadic, with the latter affecting nearly 90-95% of all diagnosed patients (Banerjee et al., 2014). In the United Kingdom (UK) in 2012, it was estimated that 127,000 people were affect (on average one person in every 500 is affected by PD) and is expected to increase to 162,000 by 2020 (Parkinson’s UK, 2012). The annual costs amount to £13,804, with £11,088 accounted for by in-formal care. Based on a prevalence of 168 of 100,000, the number of people in the UK with PD is around 100,000, and resulting in the total service costs £275 million, excluding informal care, and £1.4 billion, including informal care (McCrone et al., 2007). In comparison to the Western world, there is a paucity of research on PD in Asia. However, as PD is a disease of the elderly, it makes it an important concern for the health sector of Sri Lanka as it has a high proportion of the elderly population.

PD is defined as a movement disorder associated with the degeneration of dopamine neuron due to the development of motor symptoms such as resting tremor, muscle rigidity, bradykinesia and postural instability (Gallegos et al., 2015). During the early onset of PD, pre-symptomatic phase, the patient develops non-motor defect including olfactory impairment, vagal dysfunction and sleep disorders (Gallegos et al., 2015). Motor symptoms occur on degradation of 50-60% of dopaminergic neurons followed by cognitive decline on advancement of the disorder, i.e. 70-80% degradation of dopaminergic neurons. Braak et al., 2003, classified the degree of PD pathology into 6 stages.

In order to preclude the progression of PD there are various treatment available for early stages followed by enhanced disease stage therapies. A potential cure of PD is yet elusive and the most widely administered and cheaper form of treatment for PD is levodopa or a combination of dopamine agonist and monoamine oxidase inhibitors (MAOIs) such as (MAO)-B.

Deep-brain stimulation (DBS) does not eradicate the disease but according to research it indicated a distinct decrease in motor instability and loss of drug-induced dyskinesia which resulted in patients with prolonged quality of life and a decreased progression in the disorder (Pienaar et al., 2015). DBS is a functional neurosurgery which involves in delivering a constant electrical stimulation to a neural brain structure through implanted electrodes connected to an internalized neuro-pacemaker or stimulator (Benabid, 2003). It is a safe and effective surgery but with slight complications such as haemorrhage and infection with lesser being leakage of cerebrospinal fluid, erosion, lead fractures, hardware breakage, and battery failure in the generator (Godden, 2014).

Phase 3 clinical trial relative to DBS for PD sponsored by University of Minnesota, has been completed since 2009. It is mainly involved analysing the Unified Parkinson’s Disease Rating Scale (UPDRA) to analyse the effect in quality of life relative to day to day activity, behaviour and moods and complications of therapy of the patient.